John R. Graham is a financial, economic, and policy analyst in the health sector. His appointments include:
Senior Fellow of The National Center for Policy Analysis;
Senior Fellow of The Independent Institute;
Senior Fellow of the Pacific Research Institute;
Senior Fellow of The Fraser Institute;
Adjunct Scholar of The Mackinac Center for Public Policy;
Columnist at Forbes.com's The Apothecary blog;
Member of the Board of Visitors of The Benjamin Rush Society of medical students and physicians.

How Deval Patrick Gutted Romneycare's Market-Oriented Health Reforms

Democratic Governor Deval Patrick of Massachusetts listens to a speech by US President Barack Obama at a rally for Patrick at the Hynes Convention Center in Boston, Massachusetts, October 16, 2010. (Image credit: AFP/Getty Images via @daylife)

Six years ago today, at a majestic ceremony in Boston’s Faneuil Hall, then-Massachusetts Governor Mitt Romney signed into law “An Act Providing Access to Affordable, Quality, Accountable Health Care.” Would this law be the one that finally showed America how to expand coverage and reduce costs? “I’m optimistic, but time will tell,” Romney wrote in a Wall Street Journal op-ed. “A great deal will depend on the people who implement the program.” Fatefully for Massachusetts, and for the country, the people who implemented the program were affiliated with Mitt Romney’s Democratic successor, Deval Patrick. And therein lies a story that has not been widely told.

When Romney stepped onto that stage on April 12, 2006, he received a 30-second ovation. Behind him stood Sen. Ted Kennedy, his 1994 opponent for the U.S. Senate, and Democratic leaders of the Massachusetts legislature. George W. Bush’s Secretary of Health and Human Services, Tommy Thompson, was there. “Massachusetts is showing us a better way,” Thompson said, “one I hope policymakers in statehouses and Congress will follow to build a healthier and stronger America.”

But the bipartisan bliss didn’t last very long. Just prior to the ceremony, Romney’s aides had announced that the Governor would be vetoing several key provisions of the bill, including its employer mandate that forced all companies in the state, employing more than 10 people, to provide health coverage for their workers or pay a $295-per-person fine. Romney vetoed several other provisions of the law, including one that extended dental benefits to Medicaid patients, and another that gave certain “special status aliens” the ability to receive Medicaid benefits.

Democrats maintained their smiles on-stage, but back-stage, they fumed. Forcing employers to provide health coverage to their workers was a key component of their agenda. “I’m not happy about what he did,” House Speaker Sal DiMasi told the Boston Globe. Romney, on the other hand, considered the employer mandate to be “unnecessary and probably counterproductive.”

In the end, it didn’t matter what Romney thought about the employer mandate. The Democrats controlled 85 percent of the legislature. After the bill-signing ceremony was over, they went back to the State House and overrode each of Romney’s eight vetoes.

More crucially, as Jennifer Heldt Powell and Josh Archambault describe in a new book, The Great Experiment, it was Democrats and progressive activists who ended up implementing the Massachusetts health law, especially after Romney left office in January 2007. They took the law in a much different direction than Romney would have liked. And while Democrats have sought to credit (or blame) Romney for the passage of Obamacare, it is more accurate to say that the federal Affordable Care Act is modeled after the Democratically implemented version of the Massachusetts law, as opposed to the one that Romney had sought.

Romney’s early vision for health reform

Mitt Romney’s first opportunity to espouse a vision for health-care reform was in 1994, when he sought to unseat Ted Kennedy in the U.S. Senate. “I go across this state and I see 600,000 people who don’t have insurance,” Romney said in a televised debate with Kennedy at the very same Faneuil Hall. “I want universal coverage. I want everyone in Massachusetts and this country to have insurance.”

Romney’s 1994 approach will sound familiar to the observers of today. “I think we ought to start by saying we’re going to have portability. We’re also going to make sure people can’t be denied on the basis of pre-existing illness. We need to have a subsidy…for those people who are low-income and can’t afford insurance. We need to make sure that all people—not just corporations—can deduct, on a tax basis, the cost of their premiums. We also need to make sure there’s not discrimination in rates between big companies and small companies. All of these things, I believe, are a first step to reaching universal coverage.”

Romney didn’t win that election, in large part because he had not been prepared for a withering assault from Sen. Kennedy regarding his religious beliefs and his record at Bain Capital. But he was given another crack at solving the health care conundrum when he became governor of Massachusetts in 2003.

Previous governments wrecked the Bay State insurance market

Thanks to years of economically unsound policies, Massachusetts suffered from some of the highest health-care costs in the nation. In 1988, under Michael Dukakis, the state had passed a universal health-care plan that forced employers to cover all their workers. Businesses fiercely resisted the plan, however, and it was ultimately repealed.

In 1996, the state legislature passed the Non-Group Health Insurance Reform Act, which forced insurers in the individual market to cover everyone, irrespective of pre-existing conditions (“guaranteed issue”), and charge nearly-equal rates to the young and the old (“community rating”).

Because these reforms allowed individuals to remain uninsured until they were sick, premiums shot up for those who tried to be responsible, and buy coverage for themselves when they were healthy. (Those who received insurance through their employers were not directly affected.) More and more individuals sought free care from emergency rooms, rather than buy costly insurance that they couldn’t afford. Insurers dropped out of the market. Things got so bad that even eHealthInsurance.com, the on-line insurance broker, dropped out of the state, citing the guaranteed-issue provision.

The Massachusetts Medicaid crisis sparks action

As Jennifer Heldt Powell describes in The Great Experiment, by the time Romney assumed the governorship, Massachusetts also faced a crisis with its Medicaid program. MassHealth, the state’s Medicaid plan, had been operating under a waiver from the U.S. Department of Health and Human Services. Under the waiver, the state was receiving $385 million a year from Washington to reimburse hospitals for care given to the uninsured.

That waiver was due to expire on July 1, 2005, and was contingent on the state restructuring the program so as to direct the funding to individuals, rather than hospitals. If the state failed to achieve this, they were to lose the $385 million.

Facing these two serious and specific problems—the broken individual market and the Medicaid waiver expiry—Romney proposed a comprehensive solution. As he described it in a November 2004 op-ed for the Boston Globe, Romney’s plan—which he titled “Commonwealth Care”—would restore federal Medicaid funding, resuscitate the individual health-insurance market, and achieve near-universal coverage, without raising taxes.

Romney’s 2004 health-reform plan

“Insurers tell us they can develop plans costing less than half of today’s standard rate of $500 for an individual,” Romney wrote. Shorn of the costly mandates and restrictions originating in earlier state laws, these plans, called “Commonwealth Care Basic,” could cost much less. Romney also proposed merging the non-group and small-group markets, so as to give individuals access to the more cost-effective plans available to small businesses.

By helping the unemployed gain access to these plans, reducing insurance costs, and making sure those who were already eligible for Medicaid signed up for it, Romney argued that he could “provide coverage for two-thirds of our uninsured population.”

For the remaining one-third—the long-term unemployed and the working poor not eligible for Medicaid—Romney proposed a “Safety Net Care” program that would replace the uncompensated care pool that was reimbursing hospitals for “free” care that they were providing to the uninsured.

Romney’s proposal also included broader systemic reforms, to reduce Medicaid fraud, medical errors, and malpractice lawsuits. He proposed changing Medicaid and subsidized-care income thresholds to “include the income of a child’s parent who is not living in the home. Just because a parent has moved out shouldn’t free them from responsibility for the family. We should also look at a limited work requirement, where appropriate. Asset transfers made to meet poverty criteria must be more strictly limited.”

The Democratic alternatives to Romney’s proposal

The Democratic legislature, led by Senate President Robert Travaglini and House Speaker Sal DiMasi, was also working on a solution to the Medicaid problem. The House plan centered around a “pay or play” employer mandate, like the one that had been passed in 1988. Both the House and Senate plans dramatically expanded Medicaid, allowing the program to cover children in households making up to 300 percent of the federal poverty level (it had been 200 percent previously).

Simultaneously, a universal-coverage activist group called Affordable Care Today was preparing a 2006 ballot initiative, that proposed to achieve near-universal coverage by increasing the cigarette tax and imposing an employer mandate.

Sen. Kennedy got involved, in order to help the House and Senate reconcile their differences, and Romney went to work trying to reconcile his own plan to that of the Democrats. Key areas of disagreement included the Democrats’ desire to expand Medicaid and force employers to cover their workers. All three plans contained an individual mandate, requiring every Massachusetts resident to buy insurance, and a Health Connector that would allow the uninsured to buy regulated, private plans.

The problem was, if they kept haggling over these important details, they risked not passing any legislation at all, and losing the $385 million in federal funds. In addition, there was the possibility that the left-wing ballot initiative plan, with no input from the legislature or the governor, would become law.

So Democrats passed their bill in the fall of 2005, and Romney signed it—with his various vetoes—in the spring of 2006. A few months later, Deval Patrick succeeded Romney as Governor of Massachusetts.

Romney individual mandate was designed to require catastrophic insurance

Romney’s big idea was to free insurers from the state’s costly 1996 insurance mandates, allowing individuals to buy inexpensive insurance that would meet their most urgent needs. But the health law he signed in 2006 did not specify the types of plans that insurers were required to offer. “The specific definition of [minimum creditable coverage under the mandate] was left to the board of the Health Connector to decide,” recounts Josh Archambault.

Romney’s goal, with the individual mandate, was to require people to buy catastrophic insurance that would cover emergency care. Romney’s version of the mandate was designed to compensate for the effects of the federal EMTALA law, that requires hospitals to provide emergency care to everyone, regardless of their ability to pay. “Therefore,” writes Archambault, “the original 2005 legislation filed by Governor Romney required that Massachusetts residents carry, at a minimum, catastrophic medical coverage, or in lieu of such coverage, a $10,000 bond…an approach that tracked the Commonwealth’s requirement for automobile insurance coverage.”

However, the bill that emerged out of the Democratic legislature contained a different mandate. The Democratic version did not restrict the mandate to catastrophic insurance, and it replaced the bond provision with a direct fine. Furthermore, according to Archambault, when Deval Patrick assumed office, he populated the Health Connector board with progressives who favored mandating costly comprehensive insurance, instead of cheaper catastrophic coverage.

Romney favored expanded choice and cost-sharing; Patrick did not

Another example of the difference between the Romney and Democratic approaches was in the design of insurance options for middle-class individuals and small employers. “The Romney administration had envisioned an unsubsidized exchange program that provided small employers with a healthy defined contribution model,” writes Archambault. “The model’s goals were to move the current employer-based system to an individual purchase decision and encourage competition and consumerism.”

But that’s not what the Patrick administration implemented. Instead, Massachusetts’ “Commonwealth Choice” plan forced insurers to offer standardized “Gold,” “Silver,” and “Bronze” plans that were required to offer generous, comprehensive coverage, including mental health, substance abuse, rehab services, and vision care. Small businesses could only offer their employees plans from one of the three tiers, further limiting consumer choices. (This framework is also part of the federal Affordable Care Act.)

In the partially-subsidized system for lower-income individuals, the Romney plan sought to institute a degree of cost-sharing, so that individuals would have an incentive to avoid wasteful health spending. The Connector board, however, eliminated all cost sharing for individuals making less than 150 percent of the federal poverty level.

Merger of individual and small-group markets was largely successful

One key aspect of the Romney effort, as I discussed above, was to give individuals access to the insurance plans available to small businesses. As a result of the clumsy 1996 community-rating and guaranteed-issue mandates, it cost 40 percent more to buy insurance in the individual market in Massachusetts, relative to the small-group market.

This appears to be one aspect of the Romney plan that was implemented as he intended, by the Patrick administration. This led to a significant reduction in premium prices for people who buy insurance for themselves: somewhere between 20 and 33 percent, according to a study by Milliman actuaries Leigh Wachenheim and Hans Leida.

The legacy of Massachusetts health reform

So, for all of the back-and-forth, what did the Massachusetts law achieve? The percentage of people lacking health insurance dropped from roughly 10 percent to roughly 5 percent.

But the law didn’t eliminate uncompensated care; in 2010, the state spent $475 million on uncompensated care, compared to $708 million in 2006. Emergency room volume actually went up, from 2.9 million visits in 2006 to 3.1 million in 2010. Massachusetts residents had to wait longer to see a doctor, and doctors accepted fewer patients, under the law.

Overall health costs continued to rise, leading the state to contemplate price controls and other blunt instruments. The one notable exception to this trend was in the individual insurance market, where Gov. Patrick largely implemented Romney’s reforms intact, driving premiums significantly downward.

Romney has not directly criticized his successor

Yesterday, Deval Patrick went back to Faneuil Hall, to celebrate the sixth anniversary of Romneycare. “As a result of our successful implementation of the 2006 law,” said Patrick, “more people are covered, more businesses are offering insurance, we have healthier residents and we’ve done it all in a cost-effective and responsible manner.”

Romney himself has not emphasized the differences between his vision and Deval Patrick’s. In a May 2011 speech at the University of Michigan, Romney stood up for his reforms, defending the necessity of the individual mandate to address the problem of uncompensated care. “Our experiment wasn’t perfect,” Romney has admitted. “Some things worked, some things didn’t, and some things I’d change.”

Governor Patrick, by celebrating the Massachusetts law’s anniversary, is clearly trying to do his part to blunt Romney’s criticisms of Romneycare. Patrick, after all, doubles as a co-chair of the Obama re-election campaign.

Obamacare owes as much to Deval Patrick as to Mitt Romney

But Obamacare owes as much, if not more, to Patrick’s implementation of the 2006 law, than it does to Romney’s original design. According to a Boston Herald report from April 2006, “Democrats privately and publicly grumbled over the headline treatment being lavished on Romney by the national press for a bill they say is more of the state Legislature’s making than the governor’s.”

And this is all before you get to the important differences between a state-based health reform plan and a federal one. “Our health care plan was not designed for 50 states,” Romney said in April 2006. “It was designed for one state. We’re going to have an experiment the other 49 states can look at, elements they can adopt.”

A state-based plan is constrained by the fact that it must work within the constraints of federal law and federal programs, like Medicare, Medicaid, and the tax exclusion for employer-sponsored insurance. The reason Democrats liked Massachusetts as a model is because it largely left those big federal programs untouched.

Romney, most certainly, bears meaningful responsibility for this outcome. He did, after all, sign the Massachusetts bill into law, though he did so under the duress of the expiry of the federal Medicaid waiver. Many of the economists and staffers he worked with, such as Jonathan Gruber, were heavily involved in implementing the law. Also, Romney didn’t run for re-election in 2006; though he would have faced a tough re-election battle, if he had succeeded, he would have been able to steer its implementation in a better direction.

US President Barack Obama waves alongside Democratic Governor Deval Patrick (L) of Massachusetts after speaking at a rally for Patrick at the Hynes Convention Center in Boston, Massachusetts, October 16, 2010. Obama supported Patrick's race for another term as governor ahead of the midterm elections on November 2. (Image credit: AFP/Getty Images via @daylife)

Deval Patrick’s version of the individual mandate may sink Obamacare

Romney’s support of the individual mandate, an idea that originated at the Heritage Foundation, was a key, as liberals took advantage of the mandate to force people to buy expensive, comprehensive insurance, rather than the minimalistic catastrophic insurance that Romney sought to require. This, it turns out, is the biggest danger of mandates: they’re only as good as whoever’s in charge of implementing them.

This problem was anticipated by the numerous conservative critics of the mandate in 2006. “[The Massachusetts law] is loaded with individual mandates that have driven up the costs of health insurance in the first place,” said Grace-Marie Turner on the day the bill was signed into law. “The core flaw is that the plan forces individuals to buy health insurance, and penalizes businesses that don’t provide it, before deregulating the market for private health insurance,” observed the Wall Street Journalon the same day. It’s “a recipe for higher taxes and more government intervention down the road.”

It’s a shame that Romney hasn’t drawn more of a distinction between the reforms he sought and the ones Massachusetts got. He certainly has a case to make on that front.

Romney genuinely strove for a free-market-based solution to the grave problems with Massachusetts’ dysfunctional insurance market. But Romney put too much faith in the willingness of Democrats to implement his ideas, as opposed to their own, especially after Romney left office. Romney’s biggest mistake was the individual mandate. The individual mandate was a loaded gun that Romney handed to his opponents, who used it to force individuals to buy comprehensive insurance they didn’t need.

Ironically, it is this aspect of Obamacare’s individual mandate—the fact that it forces Americans to consume health care above and beyond their actual needs—that may be its undoing at the Supreme Court. “A young, healthy individual targeted by [Obamacare’s] mandate consumes about $854 in health services each year,” said Justice Alito in last month’s oral arguments. “Isn’t it the case that what this mandate is really doing…is requiring them to subsidize services that will be received by somebody else?”

The President’s lawyers couldn’t answer that question. And for that, they can thank Massachusetts Governor Deval Patrick.

Reading this, I’m reminded of how often I’ve pointed out that Romneycare demonstrates the same failure as all technocracy from the right: the smart people who favor such approaches have no concept of the blowback from increasing the power of government and leaving tools for the left to use toward different ends. This is why expansionist government policies used for “conservative ends” have no extended life pattern within an electoral system. The tools are left in place for perversion by the next crew in power, and they are used with gusto. One additional note: It was not a “Medicaid crisis” which precipitated Romney’s plan, unless you consider being about to lose out on a large sum of taxpayer money redistributed from other states a “crisis” … which, of course, a great many state legislators do.

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“Is not my life worth $2000?” the young woman trembled from behind her tears. After weeks of persisting pelvic pain, she finally had paid $200 to see a gynecologist, and then more for a pelvic ultra sound. The doctor told her the ultra sound showed a mass on her right ovary. It could possibly be cancer but would only be able to tell with a biopsy.

“How much will that cost?” feared to ask.

“$2000” the doctor replied.”

“I don’t have that sort of money” she panicked. “Am I going to die because I cannot afford the test?” She had spent her savings to see the doctor and calculated that it would take more than a year and a half to save enough for the biopsy. Then it would be too late. She did not have health insurance.

This story is true. It is not from an undeveloped country or in the aftermath of a natural disaster. It occurred in one of America’s major metropolitan areas to an American citizen trying to live in our country without health insurance. It is the story that 60 million Americans awaken to every day.

Luckily for this woman, the following day a free medical clinic for those who did not have health insurance had been scheduled. Her job as a restaurant night manager did not provide its employees health insurance. Her second job did not offer her sufficient hours to qualify for health insurance. Her combined salaries were not sufficient to purchase an individual policy.

Desperate, the following evening after getting off her shift and overcoming her shame of needing free care (like so many other patients) she registered at the clinic.

My wife, a psychiatrist, and I, a primary care physician, had travelled to volunteer at this one-day clinic. Because the patient was in a panic when she was first seen, she was referred to Behavioral Health where my wife was stationed. The young woman told her story, as she broke into tears asking, “Is my life not worth $2000?”

Realizing that the patient’s anxiety resulted from the despair that accompanies the uninsured when faced with a serious medical problem, and the fear of the consequences of untreated diseases, my wife reassured her that she would be cared for, and then escorted her to the director of the clinic. Arrangements were made for the completion of the evaluation and subsequent treatment for which she would not be charged.

The only detail that makes her story different from the other millions Americans, between 18 and 64 years, without health insurance is that she had the serendipity of a free medical clinic. Without the clinic, most likely she would have tried not to pay attention to her symptoms until they could not be ignored. Her story is typical of the 1200 Americans cared for at this one-day clinic and of those I cared for at the other one-day clinics across America in Little Rock, Kansas City, Hartford, Washington DC, Atlanta, New Orleans, and Charlotte. At each clinic, more than 1000 patients were cared for and referred for ongoing free care. Most of these people were working but without health benefits or self employed and unable to afford coverage. When asked why they had waited so long to seek care, all had the same reason repeated as a Greek chorus in every city: “No insurance; no doctor; no medical care.”

The illnesses these people had were the same as those of the patients in my primary care practice in suburban Boston, but the burden of disease among these patients was magnitudes greater. Instead of blood pressure of 130/84, they had pressures of 210/120. Then had been without medication for months or years. Their diabetes was untreated because they could not afford to pay to see the physician or to have their prescriptions refilled. Cholesterol and obesity were unattended. Dental decay and cataracts were ignored. Arthritis and chronic lung disease were tolerated because there was no alternative.

If they had medication it was usually taken every third day to extend the prescription. Some borrowed medication from relatives who had health insurance. One woman had not had a blood test to check the control of her diabetes for over three years. She was able to get insulin from her brother but her dose had not been adjusted in the three years. She had not idea what her blood sugar level was. She had no idea if she was developing complications of diabetes. A man continued taking a potentially dangerous blood thinning medication but had not had clotting studies in over a year. He was at risk of too much or not enough medications. Another gentleman was using “drops” for his glaucoma that his brother-in-law had given him but the drops were for allergies not glaucoma.

At each clinic, five or six people were taken by ambulance to a local emergency room for acute problems. Where would they have been if the clinics had not been? A 34-year-old man, so short of breath he could not walk to the door to the clinic, was gasping for air and sweating diffusely. Three days before he had been discharged from the CCU of the local hospital, where he had been admitted for the identical symptoms, with medications he could not afford and did not understand. EMTs were notified and raced him back to the emergency room of the same hospital.

The woman in this story is from Atlanta Georgia. She could be from anywhere in our country – except Massachusetts where the state insists all residents have health insurance, paying for those who cannot pay, so all may enjoy access to care and. Having the privilege of practicing primary care in Massachusetts for over thirty years, I have witnessed the enormous benefits of Massachusetts health reform. Volunteering at the free clinics, I witnessed the tragedy of not having access to the health care. I had not seen so much untreated illness as I saw in these clinics since I had been a medical student before Medicare and Medicaid were in effect. I was shocked. I was ashamed, as a physician and as an American. How could we have allowed this to happen? How could anyone want to stand in the way of providing the care for so many fellow citizens so they too can enjoy good health and feel proud to be an American contributing fully to our society?

Without health insurance, every day close to 20% of Americans must choose between basic necessities, food and rent, and their health and the health of their families. Very likely the woman in this story would also have overlooked her pain so she could have a roof and meals. By the time the pain could no longer be ignored, it might cost her life, and cost us many times more than earlier treatment would have.

However, the debate over health reform is not about money and it is not about the over reach of government. It is simply a question of how we want to see our selves as a society. Does anyone really wish to see his or her neighbor’s health deteriorate until the ambulance is called and little can be done? Can anyone honestly want that? The Affordable Care Act is the vision for Americans to treat their neighbors as they would their family.

Thanks for sharing your heart wrenching experiences. As a 35 year veteran of the employee benefits and healthcare industry I share your opinion that we need to reform our broken have and have not system.

It is especially interesting in an election year that we have many prominent people with family health issues. Rick Santorums little girl. Ann Romney with MS and being a breast cancer survivor. Dick Cheney’s heart transplant at age 71. Sarah Palins son. Even on the Supreme Court Justice Ginsburg is also a breast cancer survivor and John Roberts has a condition that would disqualify him under pre ex if he tried to get his own insurance.

All these folks have insurance and care yet all of the politicians are against helping normal Americans like those you described, get the insurance and care they need.

Normally when someone has first hand experience with something they become attuned to how it affects others but this group seems to miss that because they have theirs.

“she finally had paid $200 to see a gynecologist, and then more for a pelvic ultra sound. The doctor told her the ultra sound showed a mass on her right ovary. It could possibly be cancer but would only be able to tell with a biopsy.

“How much will that cost?” feared to ask.

“$2000” the doctor replied. “I don’t have that sort of money” she panicked. “Am I going to die because I cannot afford the test?”

I think your narrative shows that the debate over health reform is about a lot of things – including about money.

In fact, I think you illustrate that the major obstacle to obtaining medical care is its high cost. I would add that the high cost of medical care also explains the high cost of medical insurance.

And so, among other things, this country needs to have an honest public discussion about how a gyn exam can cost more than $200 and how a biopsy can cost more than $2,000. Americans need to understand the reasons why medical care in the U.S. is so much more expensive than in France, Switzerland, Canada, etc, etc.

IMO, physicians should be taking the lead in this discussion. Who is better qualified to explain the costs and benefits of medical care? An insurance bureaucrat? A government bureaucrat?

My opinion – an honest discussion of medical delivery costs vs. benefits has never been an important part of the public debate – and it needs to be. My opinion – physicians must take the lead in this discussion, to explain both costs and benefits. Otherwise government and insurance bureaucrats will continue to influence public opinion as they prefer and experience tells us that neither physicians nor patients will be satisfied with the outcome.

We live in Massachusetts, are self-employed, have first hand experience with the Democrats’ version of RomneyCare (/Obamacare).

Check the facts. Most people living in Massachusetts are receiving subsidies from taxpayers to pay for their healthcare. (I have read as much as 67%). That is why they like it. They don’t pay for it.

My husband and I do NOT receive subsidies from the government. For our family of four, we pay almost $30,000 per year for our mandated healthcare in Massachusetts. This is for an average family plan from Blue/Cross, including yearly deductibles, prescription deductibles, all co-pays, etc. My daughter attending school and working in New York has no coverage under our plan to see a physician and must come back to Massachusetts for this. She can go to an emergency room and a pharmacy in New York. We have often paid out of pocket for her for doctor visits. $30,000 per year.

Our costs for healthcare under Democrats’ version of RomneyCare (/Obamacare) just keep going up. This is crazy. Will everyone except the superwealthy have to receive subsidies in order to pay for mandated healthcare insurance? Can only the poor and super wealthy have healthcare in our country?

You state, “Ironically, it is this aspect of Obamacare’s individual mandate—the fact that it forces Americans to consume health care above and beyond their actual needs—that may be its undoing at the Supreme Court. “A young, healthy individual targeted by [Obamacare’s] mandate consumes about $854 in health services each year,” said Justice Alito in last month’s oral arguments. “Isn’t it the case that what this mandate is really doing…is requiring them to subsidize services that will be received by somebody else?”

That is incorrect Nothing forces people to consume health care in any system. In addition, of course low utilizers subsidize heavy users. That’s why it’s called insurance. That is the very nature of any insurance. The very fact we can’t think of health insurance as “insurance” is one of the major problems we face. We either want it to pay for everything or we want to buy it only when we need it. That’s not the way it works.

No, that’s not true. People have different risks depending on their age. So it makes much more sense to charge young people accurately for the risks they incur, and old people for the risks they incur. You can try to force young people to pay more so old people pay less, but that will simply incentivize the young to go without insurance.

… good information, Mr. Roy, but I can’t help except to feel that ultimately, you’re splitting hairs. You don’t show how Romney’s preferences or variations would have reduced costs and we don’t know that there would have been any significant difference. As long as we have an employer-based system (employer mandate or not), we’re not going to have a free market and the natural cost controls that come with it. And requiring comprehensive coverage instead of just emergency coverage makes sense in many ways. Why just wait for someone to suffer an emergency if someone can instead receive regular checkups and treatment that may prevent that costly emergency (costly to the individual and to the economic equation)? Indeed, the costs of more emergencies may well negate or override the costs of more expensive comprehensive coverage. And Romney ultimately has to take some blame for not defining the type of coverage that he preferred, don’t you think?

The real hope is the health insurance exchanges in Obamacare, which should replicate free market conditions. If access to those exchanges increases over time, then perhaps we can eventually move away from the employer-based model.

Deval Patrick…an Obama wannabe that is a direct contributor to the downfall of this country. The only hope we have is that have a Wizard of Oz type of tornado, it picks him up, and drops him somewhere south of Nantucket. His goal; to give enough cash and benefits to the non-contributors of society all for the sake of a vote. God needs to helps us and defeat scum like him and Barack Hussein Obama. His will not be kind to these pantywastes.

Deval Patrick…an Obama wannabe that is a direct contributor to the downfall of this country. The only hope we have is that have a Wizard of Oz type of tornado, it picks him up, and drops him somewhere south of Nantucket. His goal; to give enough cash and benefits to the non-contributors of society all for the sake of a vote. God needs to helps us and defeat scum like him and Barack Hussein Obama. History will not be kind to these pantywastes.